Skip to main content Accessibility help
  • Print publication year: 2013
  • Online publication date: March 2013

18 - Tuberculosis

from Section 4 - Major common infections


The problem in Africa

Tuberculosis (TB) is one of the most serious threats to public and individual health in Africa. In 1993, the World Health Organization (WHO) took the unprecedented step of declaring TB to be a global emergency. Since then, despite the WHO's Stop TB Strategy and significant strides taken in scaling up TB diagnostic and treatment services, control of the global TB pandemic has remained elusive. In 2008, there were an estimated 9.4 million TB cases globally and close to 1.8 million TB deaths (WHO, 2009a). Africa has the highest burden of disease per head of population, with an estimated incidence rate of 363 TB cases per 100 000. The driving force behind the African TB epidemic is the other major epidemic of human immunodeficiency virus (HIV) infection. Not only has HIV been responsible for the tremendous increase in numbers of TB cases seen in the region in the last 15 years, but it threatens TB control efforts by further stigmatizing the disease, complicating the diagnosis, reducing the effectiveness of treatment, increasing TB recurrence rates and facilitating the spread of drug-resistant disease.

In this chapter we discuss the epidemiology, pathogenesis, clinical features, diagnosis, treatment and prevention of TB, and explain how this fits together within a framework for TB control. In all these areas, we emphasize the strong link with HIV. The best chance of detecting the disease, curing the patients and halting transmission lies in having a strong countrywide TB control programme and effective collaborative activities with prevention and treatment of HIV, and we highlight how these should work.

Related content

Powered by UNSILO
Ait-Khaled, N, Alarcon, E, Bissell, K et al. (2009). Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues. Int J Tuberc Lung Dis; 13: 927–35.
Badri, M, Wilson, D, Wood, R. (2002). Effect of highly active antiretroviral therapy on incidence of tuberculosis in South Africa: a cohort study. Lancet; 359: 2059–64.
Cain, KP, McCarthy, KD, Heilig, CM et al. (2010). An algorithm for tuberculosis screening and diagnosis in people with HIV. N Engl J Med; 362: 707–16.
Colebunders, R, Bastian, I. (2000). A review of the diagnosis and treatment of smear-negative pulmonary tuberculosis. Int J Tuberc Lung Dis; 4: 97–107.
Corbett, EL, Watt, CJ, Walker, N et al. (2003). The growing burden of tuberculosis. Global trends and interactions with the HIV epidemic. Arch Intern Med; 163: 1009–21.
Corbett, EL, Marston, B, Churchyard, GJ, De Cock, KM. (2006). Tuberculosis in sub-Saharan Africa: opportunities, challenges, and change in the era of antiretroviral treatment. Lancet; 367: 926–37.
Daniel, TM. (1998). The early history of tuberculosis in central East Africa: insights from the clinical records of the first twenty years of Mengo Hospital and review of relevant literature. Int J Tuberc Lung Disease; 2: 784–90.
De Cock, KM, Chaisson, RE. (1999). Will DOTS do it? A reappraisal of tuberculosis control in countries with high rates of HIV infection. Int J Tuberc Lung Dis; 3: 457–65.
Diul, MY, Maher, D, Harries, AD. (2001). Tuberculosis case fatality rates in HIV prevalence populations in sub-Saharan Africa. AIDS; 15:143–52.
Escombe, AR, Oeser, CC, Gilman, RH et al. (2007). Natural ventilation for the prevention of airborne contagion. PLoS Med; 4: e68.
Gandhi, NR, Moll, A, Sturm, W et al. (2006). Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet; 368: 1575–80.
Global Advisory Committee on vaccine safety. Revised BCG vaccination guidelines for infants at risk for HIV infection. 25th May 2007. Wkly Epidemiol Rec 2007; 82: 181–96.
Golub, JE, Pronyk, P, Mohapi, L et al. (2009). Isoniazid preventive therapy, HAART and tuberculosis risk in HIV-infected adults in South Africa: a prospective cohort. AIDS; 23: 631–6.
Granich, RM, Gilks, CF, Dye, C, De Cock, KM, Williams, BG. (2009). Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet; 373: 48–57.
Grant, A, Gothard, P, Thwaites, G. (2008). Managing drug resistant tuberculosis. BMJ; 337: 564–9.
Hakim, JGTernouth, IMushangi, E et al. (2000). Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis. Heart; 84: 183–8.
Harries, AD, Zachariah, R, Lawn, SD. (2009). Providing HIV care for co-infected tuberculosis patients: a perspective from sub-Saharan Africa (State of the ART). Int J Tuberc Lung Dis; 13:6–16.
Hesseling, AC, Johnson, LF, Jaspan, H et al. (2009). Disseminated bacilli Calmette-Guerin disease in HIV-infected South African infants. Bull World Health Organ; 87: 505–11.
Jindani, A, Nunn, AJ, Enarson, DA. (2004). Two 8-month regimens of chemotherapy for treatment of newly diagnosed pulmonary tuberculosis: international multicentre randomised trial. Lancet; 364: 1244–51.
Karim, SSA, Churchyard, G, Karim, QA, Lawn, SD. (2009). HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet; 374: 921–33.
Korenromp, EL, Scano, F, Williams, BG, Dye, C, Nunn, P. (2003). Effects of human immunodeficiency virus infection on recurrence of tuberculosis after rifampicin-based treatment: an analytic review. Clin Infect Dis; 37: 101–112.
Kranzer, K, Houben, R M G J, Glynn, JR, Bekker, LG, Wood, R, Lawn, SD. (2010). Yield of HIV associated tuberculosis during intensified case finding in resource-limited settings: a systematic review and meta-analysis. Lancet Infect Dis; 10: 93–102.
Lambert, ML, Hasker, E, van Deun, A, Roberfroid, D, Boelaert, M, van der Stuyft, P. (2003). Reucrrence in tuberculosis: relapse or reinfection?Lancet Infect Dis; 3: 282–7.
Lawn, SD, Myer, L, Bekker, LG, Wood, R. (2006). Burden of tuberculosis in an antiretroviral treatment programme in sub-Saharan Africa: impact on treatment outcomes and implications for tuberculosis control. AIDS; 20: 1605–12.
Lawn, SD, Myer, L, Bekker, LG, Wood, R. (2007). Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact within an antiretroviral treatment programme in sub-Saharan Africa. AIDS; 21: 335–41.
Lawn, SD, Myer, L, Edwards, D, Bekker, LG, Wood, R. (2009). Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa. AIDS; 23:1717–25.
Lucas, SB, De Cock, KMHounnou, A, et al. (1994). Contribution of tuberculosis to slim disease in Africa. BMJ; 308: 1531–3.
Pithie, A, Chicksen, B. (1992). Fine-needle extrathoracic lymph-node aspiration in HIV-associated sputum-negative tuberculosis. Lancet; 340: 1504–5.
Sonnenberg, P, Glynn, JR, Fielding, K, Murray, J, Godfrey-Faussett, P, Shearer, S. (2005). How soon after infection with HIV does the risk of tuberculosis start to increase? A retrospective cohort study in South African gold miners. J Infect Dis; 191:150–8.
The Stop TB Strategy: building on and enhancing DOTS to meet the TB-related Millennium Development Goals. (2006). Geneva, Switzerland: World Health Organization. (WHO/HTM,STB,2006.368).
WHO and UNAIDS. (1998). Policy statement on preventive therapy against tuberculosis in people living with HIV. WHO/TB/98.255. UNAIDS/98.34. Geneva, Switzerland: WHO.
Wood, R, Liang, H, Wu, H et al. (2010). Changing prevalence of TB infection with increasing age in high TB burden townships in South Africa. Int J Tuberc Lung Dis; 14: 406–412.
World Health Organization (2004). Interim Policy on Collaborative TB/HIV Activities. Geneva: WHO. WHO/HTM/TB/2004. 330. WHO/HTM/HIV/2004.1.
World Health Organization (2006a). Guidelines on co-trimoxazole prophylaxis for HIV-related among children, adolescents and adults. Recommendations for a public health approach (2006) Available: .
World Health Organization. (2006b). Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2006 Revision. Available: .
World Health Organization (2006c). The Global Plan To Stop TB 2006–2015. Stop TB Partnership, 2006.
World Health Organization (2009a). Global Tuberculosis Control. Epidemiology, Strategy, Financing. WHO/HTM/TB/2009.411.
World Health Organization (2009b). Guidelines for the Treatment of Tuberculosis, 4th edn. Geneva, Switzerland.
World Health Organization (2009c). Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. November 30, 2009. Available: .
World Health Organization (2009d). WHO policy on TB infection control in health-care facilities, congregate settings and households. WHO/HTM/TB/2009.419. 2009.
Zachariah, R, Massaquoi, M. (2006). Cotrimoxazole prophylaxis for HIV-positive TB patients in developing countries. Tropical Doctor; 36: 79–82.